Prior Authorization Policy & Criteria Specialist

Truescripts-Management-Services; Washington (IN); On-site; USD 85,000 - 110,000; Full time

Job summary

TrueScripts Management Services is seeking a detail-oriented professional to draft and govern clinical PA criteria across our PBM platform. You will work with pharmacists and the policy committee to ensure accuracy, compliance, and timely updates.

In this role you’ll maintain Confluence logs, build criteria in the PA system, and support audits and state-specific requirements with meticulous documentation and cross-team collaboration.

Qualifications

• High school diploma required; two-year degree preferred.
• Pharmacy technician experience strongly preferred.
• Experience with pharmacy prior authorizations, PBM operations, or clinical criteria drafting strongly preferred.
• Strong research skills, including the ability to interpret FDA labeling, clinical guidelines, and drug literature.
• Excellent written communication skills for policy drafting, documentation, and cross-team communication.
• Experience with a prior authorization platform or similar processing/workflow software preferred.
• Familiarity with Confluence or similar knowledge management tools.
• Strong organizational skills and attention to detail; ability to manage multiple criteria projects simultaneously.
• Proficiency in Microsoft Office 365 (Word, Excel, Outlook, etc.).

Responsibilities

• Draft clinical criteria policies and question sets for medications requiring prior authorization, informed by current FDA labeling, clinical guidelines, and drug compendia.
• Perform initial quality checks on drafted content to ensure clinical accuracy and alignment with current guidelines before submission for pharmacist review.
• Use dashboards and reporting, with support from the Prior Authorization Coordinator Team, to proactively identify medications needing new or updated criteria.
• Submit draft criteria for formal review and approval, first by internal pharmacists, then by the policy committee.
• Prepare summary materials and supporting documentation for policy committee review and presentations.
• Maintain a master tracking log of all criteria in Confluence, with support from the Quality Committee Champion, including approval and effective dates, next scheduled review date, and version history, to ensure the annual (or sooner) review cadence is met.
• Build approved clinical criteria and question sets into the prior authorization platform.
• Develop and execute test cases to validate question logic, branching, and outcomes prior to production release.
• Migrate approved, tested policies to the production environment.
• Maintain version control across draft, approved, and production policies to avoid discrepancies.
• Build and maintain PA-related forms (e.g., prescriber fax forms, clinical information requests) and correspondence templates (approval letters, denial letters, appeal rights notices) within the prior authorization platform.
• As guided by Compliance, research and incorporate state-specific requirements — turnaround times, required notice language, appeal rights, step therapy override laws — into criteria, forms, and letters.
• As guided by Compliance, implement state-specific prior authorization requirements within the prior authorization platform, ensuring criteria, forms, and letters reflect each state's rules.
• Maintain a reference log of state-specific requirements by state and client/plan, updating it as advised by Compliance of regulatory or legislative changes.
• Implement member notification for prior authorization determinations — including approvals, denials, and appeal rights — and ensure the process remains compliant going forward.
• Serve as steward of the criteria repository in Confluence, ensuring a single, current source of truth exists for all approved criteria.
• Maintain change logs and archive retired or superseded criteria while preserving version history.
• Create and update job aids by summarizing new or revised criteria for the Prior Authorization Coordinator Team.
• Communicate new and updated criteria to the Prior Authorization Coordinator Team ahead of go-live, including any workflow or documentation changes.
• Serve as the subject matter resource for the team on how specific criteria should be applied.
• Communicate relevant updates to other internal stakeholders (e.g., Clinical, Compliance, Client Services) as needed.
• Support internal and external audits (client, URAC/NCQA accreditation, state regulatory) by providing documentation showing criteria are current, evidence-based, and properly approved.
• Audit prior authorization criteria effective dates year over year to account for plan changes (e.g., plan renewals), ensuring criteria remain aligned with current plan parameters.
• Assist with appeals or grievance reviews by supplying clinical criteria documentation and rationale.
• Manage expedited criteria development for urgent situations, such as a new drug requiring immediate PA criteria outside the normal review cycle.
• Perform other duties as assigned.

Skills

Research skills

Written communication

Analytical thinking

Independent work

Team collaboration

Education

High school diploma

Two-year degree preferred

Tools

Confluence

Microsoft Office 365

Job description

TrueScripts Management Services is seeking a detail-oriented professional to draft and govern clinical PA criteria across our PBM platform. You will work with pharmacists and the policy committee to ensure accuracy, compliance, and timely updates.

In this role you’ll maintain Confluence logs, build criteria in the PA system, and support audits and state-specific requirements with meticulous documentation and cross-team collaboration.